January 2014

Documentation Key to Core Measures Reporting
By Judy Sturgeon, CCS, CCDS
For The Record
Vol. 26 No. 1 P. 6

With all of the attention being given to the data derived from clinical information found in patient charts, physicians will be happy to learn that the world finally does revolve around them—well at least around their documentation.

Pay for Performance
Medicare and other payers are placing more of their focus and money on quality outcomes. One of the top concerns when looking at care quality is the number of hospital readmissions within 30 days of an inpatient stay. Medicare considers the following question: Were there any concerns regarding the medical care provided during the initial encounter that may have resulted in a potentially unnecessary readmission?

One way this is determined is by reviewing inpatient cases in which the patient was admitted for a diagnosis that commonly results in a readmission within 30 days. These cases are evaluated for documentation of treatments that are expected to be provided as a standard of care and for whether a well-crafted discharge plan was created to help lower the possibility of readmission.

The hospital isn’t limited to being required to follow these core measures only for Medicare or Medicaid patients. In a Medicare audit, every admission is fair game for review regardless of whether there is a federal or commercial payer or it is a self-pay or indigent care admission. The quality-of-care expectations are the standard for all patients.

Top Problem Diagnoses
Pneumonia, heart failure, and acute myocardial infarction (AMI) are three conditions at the top of the quality review hit list that are typically affected by both physician documentation and coding rules. Because cases are selected for audit based on the principal diagnosis that was coded, it is important to understand how the provider’s documentation affects the coding as well as how coding rules specific to those diagnoses may unexpectedly move a case into a core measures audit sample. In the same manner, clarification of incomplete documentation or a nonspecific diagnosis prior to coding could keep a case from being inappropriately considered as having failed quality criteria.

Reason for Admission
The principal diagnosis for an inpatient stay is defined as the condition established after study to be chiefly responsible for the patient’s admission to the hospital. If the symptoms that justified the admission are found to be due to a more specific diagnosis, then the cause usually, but not always, is the principal diagnosis.

A clinical person may assume this rule makes it easy to identify in advance the patients who will need to meet the core measures treatment and discharge planning criteria for pneumonia, heart failure, and AMI. However, there are several coding rules that may have surprising consequences.

Pneumonia
There are a large number of codes for different types of pneumonia, and not all of them are on the core measures hit list. Because the expectations for care and discharge instructions are focused on the common bacterial pneumonias, specificity is of the essence when documenting the cause and type of pneumonia.

If the pneumonia is due to tuberculosis, HIV disease, aspiration, accidental poisoning, or mechanical ventilation, then the case will not be considered for a core measures audit. The caveat is that the physician/provider must document the cause of the pneumonia. The coder may not assume the cause from the organisms identified in lab results or from the fact that the patient is on a ventilator.

Heart Failure
Take the interesting case of patients with end-stage renal disease (ESRD) who are admitted because of volume overload from noncompliance with their dialysis schedule. If the patient also has congestive heart failure (CHF), that will be the principal diagnosis, and the case will be expected to meet core measures criteria for this population. The clinical staff may not be expecting this scenario because the cause of the volume overload is the chronic kidney failure, not CHF.

How can this occur? Coding rules often require that the acute presentation of a chronic condition be sequenced as the principal diagnosis. Although the volume overload is the acute presentation, there is another coding rule that prohibits using the volume overload as principal diagnosis if the patient also has CHF. Because volume overload is considered to be inherent in the disease, when a CHF patient presents with the symptoms, then only that condition is coded. The patient admitted for a common symptom of ESRD now has a principal diagnosis of CHF and may not have received the treatment and discharge planning that is expected of the CHF core measures criteria.

There are some exceptions, though. If the physician documents that the volume overload was due to dialysis noncompliance alone and did not affect or exacerbate the CHF, then the coder will sequence the volume overload as the principal diagnosis and the patient won’t be included on the core measures list. While this is an uncommon clinical presentation, it isn’t outside the realm of possibility.

Another coding rule can impact this patient type: Should the provider document multiple reasons for admission and all are treated essentially equally, then the coder has more options. If the ESRD/CHF patient is admitted for volume overload and hyperkalemia, and the treatment for both problems is similar in therapeutic intensity, the hyperkalemia can be sequenced as the principal diagnosis instead of the CHF. That still will be reported as a secondary diagnosis but no longer will trigger a core measures expectation.

When the rules allow optional code sequencing, quality reporting staff members need to work with the coding department to determine the choice with the best overall outcomes for the facility.

AMI
When a patient is admitted for what initially is documented as an AMI, the physician must clearly state whether the infarction has been confirmed or ruled out. Coders may not assume that if the patient’s cardiac catheterization showed no coronary artery disease that the AMI was ruled out. If the final documentation notes that “hypertension caused the elevated troponin,” does that mean the hypertension caused the infarction, which caused the elevated troponin or was there only hypertension? If coronary artery disease was not found, was there still an AMI but due to some other cause? Or was there no AMI at all?

If the initial diagnosis was a type of AMI called non–ST-elevated MI (NSTEMI) and the cardiologist documents that STEMI (a different type of MI) was ruled out, the case likely will be coded with the NSTEMI that was not ruled out, resulting in the patient staying in the AMI core measures population.

Be certain that physicians clearly document when MI has been ruled out. If they don’t, a patient who obviously didn’t have an AMI may be coded as such. Keep in mind that if the documentation at discharge states that a condition still was possible, probable, or not ruled out, it will be coded as if it exists.

Final Thoughts
Should health care teams focus on making quality reports look impressive instead of providing quality care to all patients regardless of how cases are coded? Of course not. Nevertheless, if clinical teams understand the documentation and coding rules that may create an unexpected obligation for “medication or explanation,” the core measures standards always will be met and subsequent reviews will accurately reflect that quality care was provided.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 23 years.